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After reading your editorials and articles on the subject of
sponsorship, I picked up pH7 - The Parliamentary Health Magazine. I note
15 of its 55 pages contain adverts for various commercial health-related
companies, including providers of private health care.

I would like to clarify an important issue that direct marketing to
the general public is forbidden in UK, though it is "legal" in the US. Any
promotion from the pharmaceutical companies is abided by the ABPI Code of
Practice [in this case, Clause 20( Relations with the General Public and
the Media) and Clause 21(the Internet)].

Competing interests:
currently working in a CRO specialised in early phase clinical studies

The degree of influence of drug industry depends to a great extent on
the individual targetted. When will the BMJ "disentangle" from the Drug
Industry? How much was gained from the Drug adverts on this issue? (16
FULL PAGES! excluding BMA News and Classfied Ads supplement + wrappers).
Strangely, it has dropped to 16 from the 26 full pages of Drug Adverts in
the BMJ of 25th of January! This is despite charging over £300 to the
subscribers.
I shudder to think what would become of the educational courses of very
high standard that are often entirely sponsored by the Drug Industry.
Majority of the doctors are not seduced by the marketing. My observation
is that the Pharmacists in Primary Care Organisations and Nurses are far
more influenced by the drug industry over the last six years. I wonder
what research evidence we have for this. Over the last few years the
industry has been marketing directly to the public via the internet, and
media. Some academic posts too are being sponsored by the Drug Industry.
Do we have to throw away the baby with the bath water?
What is needed is "Mindful practice" by critically appraising the so
called "Evidence Based Medicine" in the light and context of our
professional practice. This requires an insight and awareness of the
hidden agendas of the person or organisation trying to influence us, by
listening to what is being said, but paying attention to what is not being
said!

Those who doubt the truth of that dogmatic statement should look at
the cartoons of Hogarth, the cartoons that David Low produced during the
Second World War, the cartoons now being drawn by Steve Bell, and all the
cartoons in between in which gifted artists made memorable comments on
none too trivial matters.

It is very appropriate that this issue of the BMJ carefully examines
the relationships between doctors and drug companies. A convincing case is
made for improvement, particularly in reporting the results of research.
Unfortunately, the illustration on the front cover is not appropriate. At
best it would be considered flippant. As a median point it could be
considered tasteless. By many it would be considered highly offensive.

Doctors are not pigs and drug company representatives are not
reptiles. Worst of all is the figure in the bottom right hand corner: most
emphatically, patients are not guinea pigs. Regrettably, it is true that
some doctors may be unduly influenced by rewards, that some companies may
not have the purest motives, and that patients may suffer because of the
publication of biased results. Surely these matters are far too serious to
be depicted in a cartoon.

This week's content of the BMJ suggests that EBM can stand sometimes
for "Evidence Based Marketing" or even "Evidence Base Misleading" instead of for "Evidence Based Medicine".
Industry seems today one of the main sources of bias in Evidence Based
Medicine.

The editorial by Jane Smith BMJ 2003;326 (31 May) prompts me to
bring out an alarming situation in underprivileged countries with regard
to physician – industry nexus. Though chemotherapy ( CT) has marginally
changed the outcome in most of the common cancers, industry is promoting
CT as option that improves quality of life or diseases free survival
without affecting survival. Impoverished nations harbor huge number of
cancer patients therefore chemotherapy industry has located a big market
in such nations. The sale of chemotherapy has increased manifolds with
static mortality rates. Few weeks of increased disease free survival or
questionable improvement in QOL hardly matters when you have to mortgage
your belongings to finance the chemotherapy. Unlike western countries,
most patients in such nation either bear the cost themselves or drain out
the limited resources of their employer. For example, the cost of 100 mg
of paclitaxel alone is approximately rupees 3500 ( $ 78) which is
sufficient to feed a poor family for 4 to 5 months.

Unwarranted use of
chemotherapy assumes greater significance in contrast to multivitamins,
cosmetic, vitality drugs etc because it is not only financially crippling
for the patient but also deprives him of whatever little good life he is
left with. The promotion and downfall of high dose chemotherapy and
autologous bone marrow transplantation is a burning example of how
patients were lured in an ineffective protocol. Chemotherapy research and
sale is propelled not by the desire to help patients, but by the avarice
of drug companies. The average cost of developing one new drug is
estimated to be $300 million to $600 million and pharmaceutical companies
spend more than $11 billion each year to promote and market their drugs.
(1)This cost of advertising (which includes gifts and other promotional
offers to the physicians) is ultimately borne by the patient! Some
companies are paying the physicians for each vial of chemotherapy that
they prescribe. It is not surprising that apart from medical oncologists,
even surgeons and radiation oncologist are showing profound interest in
chemotherapy practice. CT industry pays millions of dollars in sponsoring
the attendance of their patron physicians in international conferences and
symposias at exotic locales. Medical representatives in developing nations
have replaced the conventional continuing medical education with in-
office confusing medical education. Drug companies seek out researchers
who happen to be getting positive results. To make the situation worse
some white skinned faculty will be flown to such dark skinned nations for
presenting a nicely worded statistical jargon hyper-inflating advantages
of their products. Absence of national guidelines, poor patient awareness
and lack of dedicated cancer centers are other attributable causes to this
malpractice. Often industry sponsored clinical trials use surrogate end
points that may not even distantly correlate with more important clinical
end points and the hyper - selective projection of favorable results
overwhelms most practitioners (2,3,4,5) . The industry is diverting most
of its research and drug trials to such nations to avoid the stringent
conditions prevailing in west.

Friedberg et al. reported that 5 percent of
industry-sponsored pharmacoeconomic studies of cancer drugs reached
unfavorable conclusions about the company's products, as compared with 38
percent of studies with nonprofit funding that reached similar
conclusions. (4) Seventy percent of the money for clinical drug trials in
the United States comes from industry rather than from the National
Institutes of Health (NIH).

30th,may,2003
Dear Editor,It was interesting to see several articles published in the
BMJ,exploring the relationship between doctors and drug
industry(Journal,2003),I would like to comment on those papers,
1.Infact they discuss a very sensitive issue at present time,relationship
between drug companies,and doctors,could be also medical students(using
the concept of primacy effect in interpersonal relationships , a term
borrowed from clinical psychology),and the newly graduated doctors.
2.It is well known fact that one of the means to change public opinon
,among which are medical professionals,nursing staff,medical
organizations,medical journals...etc is by the use of financial support
which could be through direct or indirect way,supporting of
meetings,research,attendance of conferences,or present a gift to the
department,hospital or medical school,as for example a Positron Emission
Tomography ..?
3.Regarding the publication in medical journals,and presentation of papers
at conferences especially those sponsered by drug companies,I quite agree
they tend to be biased towards their product,several papers published in
different medical journals during the last century illustrate for e.g the
statistical errors are high among papers published in different medical
journals , in which they present numerical results!1,2,3,4.
4.It will be interesting to see a single study sponsered by a drug company
and either published in a medical journal or presented in a conference
which show their product either less effective than other drugs or have
more side effects?,5.

With my best regards

Yours sincerely,

Dr.A.K.Al-Sheikhli

References
1.Gore,SM,Jones IG,Rytter EC,Misuse of statistical methods:critical
assessment of articles BMJ from January to March 1976,Br Med J
1977,1(6053):85
2.White SJ,Statistical errors in papers in the British Journal of
Psychiatry,Br J Psychiatry 1979 Oct,135::336-42
3.McGuigan SM,The use of statisics in the British Journal of Psychiatry,Br
J Psychiatry 1995;167(5):683-8
4.Porter AM,Misuse of correlation and regression in three medical
journals,J R Soc Med 1999 Mar;92(3):123-8
5.Al-Sheikhli AK,Atypical antipsychotics ,less extrapyramidal symptoms
& effect on serum prolactin,but other side
effects..?,bmj?cgi/eletters/325/7358/243#24510,8 Aug 2002.